A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces a client's ability to move the arms, legs, body, or head freely. A chemical restraint is a drug used to control behavior or restrict freedom of movement that is not a standard treatment or dose for the client's condition. Seclusion is involuntary confinement of a client alone in a room or area they are physically prevented from leaving, used only for violent or self-destructive behavior.

What is and is not a restraint depends on the effect, not the device:

• All four side rails raised so that a client who wants to get out of bed cannot do so = restraint
• Side rails are not a restraint when the client cannot move voluntarily anyway, or when the client can lower them and get out safely
• Tucking sheets tightly, placing a chair so the client cannot rise, or a geri-chair tray the client cannot remove = restraint
• Devices used for routine medical procedures (e.g., arm board for an IV, postoperative positioning, protective helmets), or holding a child briefly for a procedure, are generally not counted as restraints

Ethical principles

• Autonomy and dignity — restraints restrict a basic freedom; the client's rights must be respected throughout
• Beneficence and nonmaleficence — the expected benefit must clearly outweigh substantial risks
• Least restrictive intervention — used only after less restrictive measures have failed, for the shortest possible time
• A restraint is never used for staff convenience, discipline, coercion, or retaliation, or to compensate for low staffing

Why restraints are dangerous: they do not reliably prevent falls and can increase injury. Hazards include strangulation and asphyxia (especially vest or jacket restraints and entrapment in side rails), aspiration, pressure injury, skin tears, nerve and circulation damage, deconditioning, incontinence, dehydration, worsened delirium and agitation, humiliation, and death.

Before restraint — identify the reason for the behavior

• Delirium causes: hypoxia, pain, infection, hypoglycemia, urinary retention, constipation, drug effects, alcohol or drug withdrawal
• Unmet needs: toileting, thirst, hunger, discomfort, fear, noise
• Risk to self or others: pulling at an endotracheal tube, central line, or surgical drain; violent behavior

During restraint — ongoing assessment

• Circulation distal to limb restraints: pulse, skin color, temperature, capillary refill, sensation, movement
• Skin integrity under and around the device
• Respiratory status — especially with vest or jacket restraints, which can restrict chest expansion
• Hydration, nutrition, elimination, range of motion
• Emotional state and response, level of consciousness
• Continued need — can the restraint be released?

No test decides restraint use; assessment tools support the decision:

• Delirium screening: Confusion Assessment Method (CAM / CAM-ICU)
• Sedation and agitation scales: Richmond Agitation-Sedation Scale (RASS)
• Fall risk tools (Morse, Hendrich II) — a high fall-risk score alone is not an indication for restraint
• Laboratory and bedside checks to find causes of agitation: glucose, SpO₂, electrolytes, urinalysis, bladder scan

Types of physical restraint

Orders and regulatory requirements (US hospitals, CMS)

• Must be ordered by a physician or other authorized licensed practitioner responsible for the client's care
• Never written as a standing or PRN ("as needed") order; each episode needs a new order
• In an emergency a trained nurse may apply a restraint and obtain the order immediately (during or right after application)
• Violent or self-destructive behavior: each order is limited to 4 hours for adults 18 and older, 2 hours for ages 9–17, and 1 hour for children under 9; it may be renewed within those limits for up to 24 hours, after which the practitioner must see and assess the client before writing a new order
• Face-to-face evaluation within 1 hour of starting restraint or seclusion for violent or self-destructive behavior, by a physician, licensed practitioner, or specially trained registered nurse or physician assistant; a trained RN or PA who performs the evaluation consults the responsible practitioner as soon as possible
• Non-violent, non-self-destructive restraint (e.g., to protect medical devices): renewal intervals follow hospital policy (commonly every calendar day)
• Simultaneous restraint and seclusion requires continuous monitoring — in person, or by combined video and audio in close proximity
• Deaths during restraint or seclusion, within 24 hours after removal, or within 1 week when restraint or seclusion may have contributed must be reported to CMS (generally by the close of the next business day); deaths in soft two-point wrist restraints only, without seclusion, are recorded in an internal log instead
• Staff who apply or monitor restraints must receive documented training
• Discontinue at the earliest possible time, regardless of how long the order allows

Informed consent: explain the reason to the client and family. The client's refusal does not override an emergency, but family involvement often provides a less restrictive alternative (e.g., staying at the bedside).

Listed in priority order.

1. Try alternatives first (and document them)
   • Treat the cause: pain, hypoxia, retention, infection; review drugs
   • Frequent observation, sitter or video monitoring, move closer to the station
   • Reorientation, calm voice, clocks and calendars, glasses and hearing aids, family presence, familiar objects
   • Scheduled toileting, hydration, nutrition, and activity
   • Hide or secure lines: sleeves over IV sites, abdominal binder over a feeding tube, remove unneeded devices early
   • Bed or chair alarms, low bed with floor mats
   • De-escalation for aggressive behavior
2. Safe application
   • Use the least restrictive device that works; correct size
   • Pad bony prominences; maintain the body in normal anatomic alignment
   • Secure straps with a quick-release knot or buckle to the bed frame (movable part that moves with the bed) — never to the side rail, which can injure the client when lowered
   • Fit snugly enough that the client cannot slip out, with room for two fingers between restraint and skin — neither loose nor tight
   • Elevate the head of the bed when possible (aspiration risk); never restrain a client flat supine without airway observation, and avoid prone restraint
3. Monitoring and care
   • Check circulation, skin, and breathing frequently per policy (commonly at least every 1–2 hours for non-violent restraint; for violent or self-destructive behavior, continuous observation with documented checks commonly every 15 minutes)
   • Release one limb at a time at least every 2 hours (per policy) for range of motion, skin care, and repositioning, unless it is unsafe
   • Meet basic needs: fluids, food, toileting, hygiene, comfort — these must not be neglected
   • Keep the call light within reach and keep a pair of scissors or quick-release access available
4. Reassess and discontinue as soon as the reason has resolved (e.g., delirium clears, the tube is removed, aggression subsides). A family request or an order time limit is not the criterion — the client's condition is.
5. Documentation: behavior that led to restraint, alternatives tried, order, type and site, time applied and released, all assessments (circulation, skin, respiration, needs), client response, education, and discontinuation.

Delegation: assistive personnel may apply restraints and check them after training, but the registered nurse assesses the need, the client's response, and circulation, and retains responsibility. The nurse evaluates every order independently — a provider's order does not replace professional judgment.

• Explain to the client (even if confused) and family why the restraint is used, that it is temporary, and what is needed to remove it
• Invite family to stay and help calm and reorient — this may allow earlier removal
• Teach family never to tighten, loosen, or retie a restraint and to call the nurse for any concern
• Tell the family what will be checked (skin, circulation, breathing) and how often

• Restraints are a last resort after alternatives fail — least restrictive, shortest time
• Ethical core: autonomy and dignity; never for staff convenience or punishment
• Order required; no PRN or standing orders
• Violent or self-destructive behavior: orders 4 h adults, 2 h ages 9–17, 1 h under 9; renew up to 24 h; face-to-face evaluation within 1 hour
• Tie to the bed frame, not the side rail; quick-release knot; two fingers of space
• All four side rails up to keep a client in bed = restraint
• Vest or jacket restraint → watch breathing (asphyxia risk)
• Check circulation, skin, and breathing often; release per policy for ROM and needs
• Meet basic needs (toileting, fluids, nutrition) — the priority during restraint
• Remove when the risk that prompted it has resolved; document everything